Getting everyone vaccinated in the United States has become much harder now that demand for the COVID-19 vaccine is flagging. America’s vaccination strategy needs to change to address this, and it starts with understanding the specific reasons that people have not been vaccinated yet.
The conventional approach to understanding whether someone will get vaccinated is to ask people how likely they are to get the vaccine and then build a demographic profile based on their answers: Black, white, Latinx, Republican, Democrat. But this process isn’t enough: Just knowing that Republicans are less likely to get vaccinated doesn’t tell us how to get them vaccinated. It’s more important to understand why people are still holding out, where those people live and how to reach them.
After conducting a national survey of U.S. adults, we grouped people into distinct profiles based on shared beliefs and barriers to getting the vaccine. This approach, borrowed from the marketing world, is called psychobehavioral segmentation. It will allow health officials to target their strategies in ways that ignore demographic categories, like age and race. We used this approach to identify four distinct personas of vaccine hesitant people: the Watchful, the Cost-Anxious, the System Distrusters and the Covid Skeptics. People in each segment share some beliefs and barriers about COVID-19 vaccination. And each persona includes at least some of every demographic: Republicans, Black people, the middle class, young people and others.
Covid Skeptics are at the far end of the spectrum as the least likely to get vaccinated. The primary barriers for people in this group are their specific, deeply held beliefs about COVID-19. Everyone in this group believes at least one conspiracy theory related to the pandemic, whether it’s that microchips are implanted with the Covid vaccine; that COVID-19 has been exploited by the government to control people; or that the pandemic was caused by a ring of people who secretly manipulate world events.
We found Covid Skeptics are common in Arkansas, North Dakota and Nevada. Considering that 84 percent of this group believe that the government is exploiting COVID-19 to control people, leaders of vaccination campaigns should consider tapping nonpolitical figures to mobilize this group. Doctors are trusted by 50 percent of this group, while scientists are trusted by 32 percent. They could also use religious leaders, who may resonate best with 9 percent of group members who say the vaccine goes against their religious beliefs. The key to engaging this group will be to avoid trying to debunk what they believe; rather, experts need to listen, to acknowledge the group’s feelings and then share the facts. Our research finds that emphasizing that vaccination is their own, personal choice — one that can help them protect friends and family members — can also work.
The System Distrusters believe that the health care system doesn’t treat them fairly. Most, but not all, members of this group are people of color, and they prevail in Washington, D.C., Maryland and Georgia.
It will be important for public health officials to hold conversations — formal or informal — with trusted members of System Distrusters’ communities to address concerns and be transparent about efforts to vaccinate underserved communities. People in this group have low expectations that other members of their communities will get vaccinated, so making vaccinations of people they know as visible as possible will be important. Illuminating efforts to ensure that the vaccine rollout is equitable and sharing that with the community is key.
The Cost-Anxious worry about the time and potential expense of getting vaccinated (even if it is actually free). We learned they’re dominant in states like Mississippi, where they make up 23 percent of the population, which is not surprising due to the state’s high poverty rates and low Medicaid coverage.
Public health experts have stressed the need to bring vaccines to the people; with no group is this truer than with the Cost-Anxious. Holding vaccination clinics in non-health-care locations that people frequent — like workplaces, religious venues, day care centers, supermarkets, bars and restaurants — will be critical.
For this group, vaccination campaign leaders should stress that vaccination is totally free and encourage local businesses to provide paid time off for both doses.
The Watchful are holding out to see what kind of experience their friends or neighbors have with the vaccine before committing themselves. They dominate in Delaware, making up 17 percent of the state’s population, as well as 12 percent in Hawaii and Rhode Island.
Behavioral science researchers know that establishing norms can lead to the acceptance of products and could help persuade the Watchful. Encouraging those who are vaccinated to show their vaccination status with pride, both online and offline, can nudge their family, friends and networks to follow suit. The Watchful are already likely to wear masks, showing an intent to comply with social norms, so they may respond to altruistic messages about vaccination and get vaccinated to protect others.
For this group, experts should consider allowing for a “vaccinate later” option. Behavioral science suggests that people prefer moderate or “compromise” options over their extreme counterparts. Being able to opt-in to vaccines down the road may provide a comfortable alternative for this group.
President Biden’s goal to have 70 percent of the population vaccinated by the Fourth of July will be tough to meet without understanding what drives lower vaccine confidence and where various strategies to combat it will be most effective. And we can’t stop at the state level; we need to go county by county and ZIP code by ZIP code, offering specific, localized solutions to persuade the holdouts. It will also be important that all people — not just the health care professionals and the politicians — do their part. It won’t be easy, but it must be done to ensure that more people get vaccinated.
Dr. Sema K. Sgaier is a co-founder and the CEO of Surgo Ventures and an adjunct assistant professor at the Harvard T.H. Chan School of Public Health.